Paediatric- core conditions 2 Flashcards
Coeliac disease
Sensitivity to the protein gluten. Repeated exposure leads to villous atrophy which in turn causes malabsorption. Children normally present before the age of 3 years, following the introduction of cereals into the diet. Strongly associated HLA-DQ2 and HLA-DQ8. Associated with type 1 diabetes
Coeliac disease: symptoms
- failure to thrive
- diarrhoea
- Nausea and vomiting, Steatorrhoea
- abdominal distension
- older children may present with anaemia
- many cases are not diagnosed to adulthood
- Dermatological: dermatitis herpetiformis
Diagnosis and management: coeliac disease
- OGD and duodenal/jejunal biopsy showing subtotal villous atrophy, must be done before gluten is removed from the diet
- Histology: sub-total villous atrophy, crypt hyperplasia and intra-epithelial lymphocytes
- anti-endomysial and anti-gliadin antibodies are useful screening tests
- Anti-TTG IgA antibodies are measured first line and an IgA level
Management: life long gluten free diet, regular monitoring
Coeliac disease: complications
- Anaemia (secondary to iron, B1 or folate deficiency)
- Hyposplenism (and therefore a susceptibility to encapsulated organisms)
- Osteoporosis (a DEXA scan may be required)
- Enteropathy-associated T cell lymphoma (EATL; a rare type of non-Hodgkin lymphoma)
Normal bowel function
The frequency at which children open their bowels varies widely but generally decreases with age from a mean of 3 times per day for infants under 6 months old to once a day after 3 years of age.
Constipation: Child <1 year
- Stool pattern: fewer than 3 complete stools per week (does not apply to exclusively breastfed babies after 6 weeks of age). Hard large stool. Rabit droppings (type 1)
- Associated symptoms: distress on passing stool, bleeding associated with hard stool, straining
- History: previous episodes of constipation, previous or current anal fissure
Constipation: Child >1 year
- Stool pattern: Fewer than 3 complete stools per week (type 3 or 4). Overflow soiling (very loose, very smelly, stool passed without sensation). Rabbit droppings (type 1). Large, infrequent stools that can block the toilet
- Associated symptoms: Poor appetite that improves with passage of large stool. Waxing and waning of abdominal pain with passage of stool. Evidence of retentive posturing (typical straight legged, tiptoed, back arching posture), Straining, Anal pain
- History: Previous episodes of constipation, previous or current anal fissure, Painful bowel movements and bleeding associated with hard stools
Causes of constipation
- Idiopathic
- Dehydration, low fibre diet
- Medication i.e. opioids
- Anal fissure
- Over enthusiastic potty training
- Hypothyroidism, Hypercalcaemia
- Hirschsprungs disease
- Learning disability
Constipation: red flags suggesting underlying disorder
- Constipation is reported from birth or the first few weeks of life
- Passage of Meconium >48 hours
- Ribbon stools
- Faltering growth is an amber flag
- Previously unknown or undiagnosed weakness in legs, locomotor delay
- Abdominal distension
- Amber flag: disclosure of evidence that raises concerns over possibility of maltreatment
What to do if faecal impaction is present
- polyethylene glycol 3350 + electrolytes (Movicol Paediatric Plain) using an escalating dose regimen as the first-line treatment
- add a stimulant laxative if Movicol Paediatric Plain does not lead to disimpaction after 2 weeks
- substitute a stimulant laxative singly or in combination with an osmotic laxative such as lactulose if Movicol Paediatric Plain is not tolerated
- inform families that disimpaction treatment can initially increase symptoms of soiling and abdominal pain
Constipation: Maintenance therapy
- first-line: Movicol Paediatric Plain
- add a stimulant laxative if no response
- substitute a stimulant laxative if Movicol Paediatric Plain is not tolerated. Add another laxative such as lactulose or docusate if stools are hard
- continue medication at maintenance dose for several weeks after regular bowel habit is established, then reduce the dose gradually
- Don’t use dietary intervention alone, though ensure the child has adequate fibre and fluid
Constipation: advice for infants
- Infants not yet weaned (<6 months): for bottle fed infants give extra water in between feeds, try a gentle abdominal massage and bicycling the infants legs. For breast fed infants, constipation is unusual and organic causes should be considered
- Infants who have or are being weaned: offer extra water, diluted fruit juice and fruits. If not effective consider adding lactulose
Hirschsprungs disease
- The distal colon is not innervated correctly, the resulting aganglionic colon is shrunken and cant distend properly, causes a back pressure of stool in the more proximal colon
- Symptoms: delay in passing meconium (>48h), distended abdomen, forceful evacuation of meconium after digital rectal examination
- Diagnosis: rectal suction biopsy
- Management: removal of section of aganglionic colon and healthy bowel is pulled through
Diagnosis of diabetic ketoacidosis
Characterised by hyperglycaemia, acidosis and ketonaemia
Diagnosis:
* Ketonaemia: 3mmol/L and over
* Blood glucose over 11mmol/L
* Bicarbonate below 15mmol/L or venous pH less than 7.3
Diabetic ketoacidosis: causes and presentation
Causes: infection, dehydration, fasting. There shouldn’t be a fever in DKA, so if there is it means infection is the cause
Presentation: smell of acetone (fruity breath), vomiting, dehydration, abdominal pain, hyperventilation (kussmaul), Hypovolaemic shock, drowsiness, coma
Diabetic ketoacidosis: Management
- If patient is alert, not significantly dehydrated and able to tolerate oral intake without vomiting –> encourage oral intake and give subcutaneous insulin injection
- If patient is vomiting, confused, or significantly dehydrated –> give IV fluids (initial bolus of 10ml/kg 0.9% NaCl then discuss with a senior) and insulin infusion at 0.1 units/kg/hour 1hr after starting IV fluids. If there is evidence of shock, the initial bolus should be 20ml/kg.
- If patient is shocked or comatose –> ABCDE approach for emergency resuscitation
- Do not stop intravenous insulin infusion until 1 hour after subcutaneous insulin has been given.
Diabetic ketoacidosis: cerebral oedema
Major complication of DKA, can occur hours after. May be due to the rapid provision of IV fluids which causes water to move from the blood into the tissues which in the brain causes swelling of the structures in the skull.
Enuresis
The majority of children achieve day and night time continence by 3 or 4 years of age. Enuresis may be defined as the ‘involuntary discharge of urine by day or night or both, in a child aged 5 years or older, in the absence of congenital or acquired defects of the nervous system or urinary tract’
Types of nocturnal enuresis
Nocturnal enuresis can be defined as either primary (the child has never achieved continence) or secondary (the child has been dry for at least 6 months before).
Nocturnal enuresis: Management
- Underlying cause: constipation, diabetes mellitus, UTI if recent onset
- General advice: fluid intake, toileting patterns (encourage to empty bladder regularly during the day and before sleep), lifting and waking
- Reward system i.e. star charts: for agreed behaviour rather than dry nights i.e. using the toilet before sleep
- Enuresis alarm: first line for children, have sensor pads that detect wetness, high success rate
- Desmopressin: particularly if short term control is needed i.e. for sleepovers or an enuresis alarm is ineffective
